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McRAM Cmmunity QuestionnairePage 1 of 5

1GENERAL INFORMATION
1.1Form serial Number
1.2Date of survey(dd /mm / yy)
1.3Time of survey(hh / mm)
1.4Interviewer Name
1.5District
1.6Tehsil
1.7Union Council
1.8Village / Site name
1.9Latitude
1.10Longitude
1.11Site identification number
2BASIC INFORMATION
2.1BACKGROUND INFORMATION
2.1.1 Mother tongues of people residing at this site.
(select all relevant)
2.1.1.aLanguage / List
2.1.1.bLanguage / List
2.1.1.cLanguage / List
2.1.1.dOther, please specify
2.1.2 What are the nationalities of the population at this site?
(select all that are relevant)
2.1.2.aNationality / List
2.1.2.b Nationality / List
2.1.2.cOther, please specify
2.1.3 The site is accessible by:
(select all relevant)
2.1.3.a 4*4 / 2.1.3.bCar
2.1.3.cLarge Truck / 2.1.3.dSmall Truck
2.1.3.eTrain / 2.1.3.fBy foot / Boat only
2.1.3.gOther Specify:
2.1.4 What type of settlement is this?
(select one only)
O / Collective centre
O / Informal camp
O / School
O / Spontaneous settlement
2.1.5 What is the geographical terrain of the site?
(select one only)
O / Coastal area
O / Hill top
O / Mid slope
O / Open flat field
O / Steep slope
O / Valley
O / Other
2.1.5.aOther,(Please specify)
2.2SITE POPULATION
Numbers only
2.2.1 Families residing at this site
2.2.2 People residing at this site
Population / Male / Female
2.2.3 Infants < 1 year
2.2.4 Infants1-5 years
2.2.5 Children 6-11 years
2.2.6 Childs 12 - 17 years
2.2.7 Adults (18 or above)
2.2.8 Have any organizations been working with the people in this site?
Name of organisation: / Activity before emergency: / Activity since emergency:
2.2.8.a
2.2.8.b
2.2.8.c
2.3VULNERABLE POPULATION (Insert numbers)
Male / Female
2.3.1 Separated children(0-18 years old)
2.3.2 Orphaned children (0-18 years old)
2.3.3 Children who have lost their mother
2.3.4 Children who have lost their father
2.3.5 Children who have lost both parents
2.3.6 Infants without mothers
2.3.7 Unaccompanied children
2.3.8 Unaccompanied elderly people
2.3.9 Physically disabled adults
2.3.10 Mentally disabled adults
2.3.11 Mentally and or physically disabled children
2.3.12 Unaccompanied womenwithout children
2.3.13 Unaccompanied women with children
2.3.14 How many households have 5 or more dependents? / %
3WATER SANITATION HYGIENE
3.1WATER
3.1.1 From where do you get drinking water at this site? / Rank up to 3 / Sufficient /
Not sufficient
3.1.1.a Canals / ponds / rivers / streams
3.1.1.b Natural springs
3.1.1.c Protected well/spring
3.1.1.d Unprotected well / spring
3.1.1.e Protected hand pump
3.1.1.f Unprotected hand pumps
3.1.1.g Piped water supply
3.1.1.h Bowser/tanker
3.1.1.i Other improved sources
3.1.1.j Other unimproved sources
3.1.1.k Don’t know
3.1.2 What major level water treatment practices are present at this site? / Select one only
3.1.2.a Disinfection / O
3.1.2.b Boiling / O
3.1.2.c Filter and stand / O
3.1.2.d Solar / O
3.1.2.e None / O
3.1.3 How is water stored at the household level? / Select one only
3.1.3.a Decantered storage / O
3.1.3.b Closed storage / O
3.1.3.c Open storage / O
3.1.3.d Dirty vessels / O
3.2SANITATION
3.2.1 Where do people defecate? (Select all those apply)
3.2.1.aLatrines (Communal)
3.2.1.bNear to shelter (excrement removed)
3.2.1.cNear to shelter (excrement left)
3.2.1.dOpen field (away from shelter)
3.2.1.eif Others please specify
3.2.2 If defecation takes place at latrines, how many are there? / Male / Female / Combined
3.2.2.aAvailable
3.2.2.bFunctional
3.2.3 Are these latrines sufficient to satisfy the needs of all the people at the site? (Select one only)
O / Yes
O / No
3.2.2 Are water and soap being used to wash hands after defecation?
(Select one only)
O / Yes, water and soap
O / Only water
O / Neither water or soap
O / DK
O / NA
4.1.LIVELIHOOD / AGRICULTURE
4.1.1.Before the emergency, what were the main sources of income for this community?
Rank 3 main sources only / Winter
(Rank 1-3) / Summer
(Rank 1-3)
4.1.1.a.Farming /Landowner
4.1.1.b.Income support
4.1.1.c.Fishing
4.1.1.d.Livestock
4.1.1.e.Remittances
4.1.1.f.Services (Govt. or private employee)
4.1.1.g.Sharecropping
4.1.1.h.Shopkeeper / trader
4.1.1.i.Skilled wage labor
4.1.1.j.Unskilled wage labor
4.1.1.k.Don’t Know
4.1.1.l.Other
4.1.2.How badly has the main source of income (as mentioned above) been affected by the crisis?
Select one only
O / Not at all
O / Moderately
O / Badly
O / Don’t know
4.1.3.What major share of livestock was lost as a result of the crisis?
(Tick one in row only) / None / Less than half / Half / More than Half / All / Don’t know / Not applicable
4.1.3.a.Buffaloes / O / O / O / O / O / O / O
4.1.3.b.Camels / O / O / O / O / O / O / O
4.1.3.c. Cows / O / O / O / O / O / O / O
4.1.3.d.Donkey/mules / O / O / O / O / O / O / O
4.1.3.e. Horses / O / O / O / O / O / O / O
4.1.3.f.Oxen / O / O / O / O / O / O / O
4.1.3.g. Poultry / O / O / O / O / O / O / O
4.1.3.h.Sheep/goats / O / O / O / O / O / O / O
4.1.4.What major share of agricultural output was lost as a result of the crisis?
(Tick one in row only) / None / Less than half / Half / More than Half / All / Don’t know / Not applicable
4.1.4.a.Standing food crops / O / O / O / O / O / O / O
4.1.4.b.Standing cash crops / O / O / O / O / O / O / O
4.1.4.c.Standing fodder crops / O / O / O / O / O / O / O
4.1.4.d.Food stock (grains / seeds) / O / O / O / O / O / O / O
4.1.4.e.Form forestry / O / O / O / O / O / O / O
4.1.4.f.Fishery (ponds) / O / O / O / O / O / O / O
4.2.FOOD SECURITY
4.2.1.How many days in the past week did people at this site eat the following foods? What was the main source?
Food items / Number of days eaten
(1-7) / Main food sources
1-Own Production
2-Hunting, Fishing
3-Gathering
4-Borrow
5-Purchase
6-Exchange labor for food
7-Exchange items for food
8-Gift (food) from family
9-Food aid (NGOs etc)
10-Other specified
4.2.1.a.Wheat
4.2.1.b.Rice
4.2.1.c.Maize
4.2.1.d.Potatoes
4.2.1.e.Fish
4.2.1.f.Meat
4.2.1.g.Pulses/ Lentils / Beans
4.2.1.h.Oil/ Butter/ Ghee
4.2.1.i.Vegetables
4.2.1.j.Fresh fruits
4.2.1.k.Sugar/ sugar products
4.2.1.l.Milk/milk products
4.2.1.m.Condiments
4.2.2.How many meals did people at this site eat yesterday?
4.2.2.a.Adults (18+)
4.2.2.b.Children (< 17 years of age)
4.2.3.How long do you have food stocks available at this site?
(select one option) / No food Stock / 2-4 weeks / <2 weeks / <1 weeks / Don’t know
O / O / O / O / O
  1. EDUCATION

5.1Number of schools at the site
Level / Number / Status
1-Occupied by IDPs
2-Vacant
Primary
Middle
High
Higher Secondary
Private
Others (Communal schools)
5.2Number of teachers available at the site? / Male / Female
Host government teachers
IDP government teachers
Host Para-teachers
IDP Para-teachers
5.3At this site how many schools have the following facilities: / Water supply / Electricity
Primary
Middle
High
Higher Secondary
Private
Others (Communal schools)
5.4Number of latrines in the school / Numbers
Primary
Middle
High
Higher Secondary
Private
Others (Communal schools)
6NUTRITION
6.1Since the crisis, have there been any donations/ distribution of infant feeding supplies?
(select all the relevant options)
6.1.aNo distribution
6.1.bBottles
6.1.cDry milk
6.1.dInfant formula
6.1.eLiquid milk
6.1.fTeats
6.1.gDon’t know
6.1.hNot applicable
6.1.iIf other, please specify
6.2Are there any pregnant or lactating women at the site?
O / Yes
O / No
6.3If yes, have there been any changes in breast-feeding since the crisis? (Select one only)
O / More women breast-feeding
O / Less women breast-feeding
O / No change, the same number are breast-feeding
O / Don’t know
6.4If less women breast-feeding, what are the problems experienced?
Rank the below options (1,2,3)
6.4.aLack of privacy / space
6.4.bNo/less breast milk (perhaps due to stress or poor health)
6.4.cOther
6.4.dIf other, please specify
6.5Has there been any change in feeding practices for children aged between 6 to 24 months since the crisis?
(select all the relevant options)
6.5.a Breast-feeding stopped
6.5.bBreast-feeding reduced
6.5.cComplementary feeding quantity increased
6.5.dComplementary feeding quantity decreased
6.5.eNo change
6.5.fIf other, please specify
7.1HEALTH
7.1.1.Has there been an increase in a specific disease lately in this community?
O / Yes
O / No
7.1.2.If yes please name those diseases
5
6
7
7.1.
7.1.1.
7.1.2.
7.1.2.a.Disease 1
7.1.2.b.Disease 2
7.1.3.Has there been any unusual increase in number of deaths in this community?
O / Yes
O / No
7.1.4.What health facilities / Services are available to the community?
(select all the relevant options)
7.1.3.
7.1.4.
7.1.4.a. Male Medical Officers (Male Doctors)
7.1.4.b. Female Medical Officers (Lady Doctors)
7.1.4.c. Medical Technician/ Dispenser
7.1.4.d. LHV
7.1.4.e.Free medicines
7.1.4.f.Antenatal services
7.1.4.g.Delivery services
7.1.4.h.Family planning services
7.1.4.i.Ambulance services
7.1.4.j.Vaccination services
7.1.4.k.Basic Laboratory services
7.1.4.l.No one
7.1.4.m.Don’t know
7.1.4.n.Other, specify
7.1.5.To where do serious cases get referred to
7.1.6.How far is the referral service? (InKM)
7.1.7.What transport options are available for referral patients?
(select all the relevant options)
7.1.5.
7.1.6.
7.1.7.
7.1.7.a.Ambulance (Government)
7.1.7.b.Ambulance (Private /Social services)
7.1.7.c.Private transport
7.1.7.d.Own transport
7.1.7.e.By foot
7.1.7.f.None
7.1.7.g.DK
7.1.7.h.Other specify
7.2.Reproductive Health
7.2.1.No of pregnant women in this household?
7.2.2.How many currently pregnant women are receiving antenatal care by a skilled birth attendant?
7.2.3.How many women are there in this household whose most recent pregnancy ended in a live birth or still birth in the last two years?
7.2.4.How many women are there in this household whose most recent pregnancy ended in a live birth or still birth in the last two years?
7.2.5.How many married women in this household are (insert number of women)
7.2.5.a.Not using family planning methods
7.2.5.b.Intend to use a method to delay or avoid pregnancy
7.2.6.What is the total number of women who visited health facilities with complaints of vaginal discharge/fluid discharge during the last six months?
  1. SHELTER

8.1Rank the 3 top housing concerns for IDP’s?
Concerns / Ranking (1-3)
7
8
8.1
8.1.aOvercrowding
8.1.bSecurity
8.1.cPrivacy
8.1.dHot summer conditions
8.1.eLack of water & Sanitation
8.1.fLack of cooking facilities/Utensils
8.1.gHigh costs of goods/services
8.1.hLack of money
8.1.iOther specify ______

McRAM Cmmunity QuestionnairePage 1 of 5